In the following text I would like to give the reader a short overview of this medical field that is very important not only for the patient suffering from a rheumatic disease but also for society because such diseases are a considerable strain on healthcare budgets around the world..
It is not an easy task to define the field of rheumatology. It deals primarily with chronic diseases of the locomotor system that includes mainly joints, the spine, muscles and tendons. The rheumatic diseases are a collection of around 400 different disorders that can be very different in their impact on the patient, the long-term prognosis and the necessary treatment. One of the most important tasks of the rheumatologist is therefore to find the correct diagnosis.
To bring a little structure into this huge field I would like to divide it into 3 main parts:
- The inflammatory rheumatic diseases
- The chronic-degenerative diseases
- The diseases of other fields that include rheumatologic symptoms
The inflammatory rheumatic diseases have one common aspect – they are caused by autoimmune processes meaning that the immune system that is ceaselessly working on defending the body against outer enemies like bacteria or viruses is defective in a way that it is fighting the body’s own tissues. These processes affect mostly joint capsules, connective tissue and the tissues surrounding tendons. This explains why all the classical symptoms of an inflammation can be found at the afflicted structures – e.g. in a joint it could be pain, swelling, redness, warmth and an impaired function. On the other hand, it is important to mention that the autoimmune process not only can attack the above mentioned structures, but also a wide variety of other tissues, explaining the overlap of an inflammation of the locomotor system and a wide variety of other tissues like skin, inner organs and many more. Often the general wellbeing of the patient is affected by tiredness, loss of activity and even depression. The most frequent inflammatory rheumatic disease is the rheumatoid arthritis. Here, especially in the beginning mainly the small joints of fingers and toes are affected, later followed by bigger joints as knees, shoulders and hips. The inflammation in the joints produces swelling of the joint capsules and the movement is restricted, a classic symptom is a stiffness of the joints in the morning hours. About 1% of the world population is suffering from this disease, women three times more frequent than men. As it is caused by an autoimmune process, it is typical that the inflammation can also be detected in the blood and this result is important to find the adequate therapy. If the disease is not treated efficiently, damages to the joint structures and later the adjoining bones itself can occur and lead to irreversible destruction of joints with the resulting handicap.
Luckily today we have an arsenal of drugs that can stop the disease in a lot of cases or at least make the course much slower and less aggressive. The standard medication is from the group of immunosuppressants. The most important ones are the so called “disease modifying anti-rheumatic drugs” (DMARDs). They reduce the exaggerated activity of the immune system, but this is always an act of balance, because the normal functions of the immune system have to be maintained to allow e.g. for the necessary defence against infectious diseases. The classical medication of this kind (beside some others) is Methotrexate that is given in a low weekly dosage. The drugs of this type normally need some time to establish the full effect on the inflammation process (weeks to months) straining the patience of those suffering from it. In the long run, these medications can stop the destructive process of the disease to a high percentage but require ongoing monitoring of the patient. As a combination with these substances, corticosteroids are a valuable supportive tool especially in the waiting period when an effect of the DMARDs is not yet achievable. However, higher dosages for a long time should be avoided. But sometimes a combination of DMARDs with low – dosage cortisone is the best option. In the last years a new type of medication, the so called “biologicals”, were developed that work on specific pathways of the immune system and add to the possible remedies. Whereas the name implies a natural and maybe softer action, this is not the case. They are very efficient, but can produce very serious side effects, so that they are mostly given in combination with other DMARDs in severe cases. They should only be administered by experienced specialists in the field. Quite often the DMARD therapy is effective in the majority of the affected joints, but some joints react less favourably. Then the typical way to check the joint is an echography, an x-ray or a MRI. The rheumatologist can then provide relief by doing targeted local therapy like joint punctures with anti-inflammatory substances or infiltrations of the surrounding tissues. If ,unfortunately, it is not possible to stop the disease process before serious joint damage occurs, surgical procedures may be necessary not only in the form of joint replacement but before this last resort is necessary in the form of so called synovectomies where the inflammatory tissue of the joints is taken out to minimize the inflammation process. It should not be forgotten that a continuous physiotherapy is a very important addition to the therapeutic spectrum that can restore a lot of lost mobility for many patients. In conclusion the treatment of inflammatory rheumatic diseases needs a continuous care of the patient and the specialist always must have a clear overview of all the possible options.
The chronic-degenerative diseases can be seen as the outcome of the wear and tear process of structures of the locomotor system, affecting mostly weight-bearing joints like knees or hips. The typical example is an osteoarthritis. In comparison with the inflammatory diseases they are not affecting the immune system and therefore do not produce traces in the blood. Often medication with painkillers is necessary to keep the patient mobile. To increase the stability of the joint cartilage oral therapy with cartilage building blocks is sometimes attempted, yet the results are often disappointing. More efficient is the application of substances like hyaluronic acid directly into the joint via a puncture. Repeated applications of this method can maintain the function of a huge number of joints that otherwise would have to be operated with joint replacement.
The joint replacement operation is nowadays quite often very efficient and has long standing success, but is always a last resort. There are other surgical procedures (so-called synovectomies) that try to improve the joint function, typically performed with keyhole technique, where the destructive inflammation tissue is removed. In the majority of cases they can only stretch the time period until replacement is necessary. So it is important to always check the benefit to risk ratio of these methods. The implantation of stem-cells is still in the experimental stage, but could someday be helpful to stabilize the damaged cartilage. In conclusion, the chronic-degenerative diseases of the joint are not directly affecting the whole body. That makes it clear that the therapy is centred directly on the affected joint and involves less medication and more often local therapy and finally as a last resort surgery.
The locomotor system can be affected by a variety of diseases that are systemic, involving the whole body. For example, it is common knowledge that during a mild virus infection like a common cold muscles and even joints can hurt. And in this way many illnesses from the field of internal medicine can have symptoms in the locomotor system, so that one task of the rheumatologist is to check if symptoms that are resembling a rheumatic disease are possibly caused by other diseases and are only collateral and temporary.
A frequent disease that falls into this third category is the fibromyalgia, where the patient has severe pain in a variety of tender points which are located normally at spots where ligaments are attached to the bones. This is going along with general symptoms like fatigue, depression, insomnia and headaches. Whereas the most noticeable symptoms are clearly related to the locomotor system, the cause is often found in lower levels of a brain neurotransmitter called serotonin, which leads to lowered pain thresholds or an increased sensitivity to pain. So the fibromyalgia is a disease of pain reception and when tender points are examined, no change in the underlying structures of muscles or ligaments can be found. The appropriate therapy is therefore to increase the amount of serotonin in the brain by drugs and giving pain reducing medications.
Of course this introduction can only give a very rough impression of the medical field of rheumatology but hopefully the reader can benefit from it and obtain a clearer picture of when they have to look for the help of a rheumatologist.
August 17, 2016
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